ALIQOPA (copanlisib)

ALIQOPA (copanlisib)

OFFICE ADMINISTRATION - MEDICAL BENEFIT

Indications for Prior Authorization:

• Treatment of adult patients with relpased follicular lympohma (FL) who have received at least two prior systemic therapies

Patients must meet the following criteria for the indication(s) above:

• Prescribed by an oncologist, AND
• 18 years or older, AND
• Chart note documentation confirms diagnosis of relapsed follicular lymphoma (FL), AND
• Patient has tried and failed at least two prior systemic therapies

Dosing:

• 60 mg administered as a 1-hour IV infusion on days 1, 8, and 15 of a 28-day treatment cycle on an intermittent schedules (three weeks on and one week off).  Modify dosage for toxicity.  Continue treatment until disease progression or unacceptable toxicity.